Multnomah County Health Department
Portland, OR

April 2000

        §       Background

In an effort to improve the community's health status through collaborative action, the Multnomah County Health Department joined with local healthcare providers to establish the Oregon Health System in Collaboration (OHSIC) in 1993.  Through its roles as a member of OHSIC, the Multnomah County Health Department has been actively involved in a variety of different community health initiatives, including a initiative beginning in 1996 to address access to healthcare among the county's uninsured population.  The 1996 efforts were cut short by a safety net funding crisis brought about by a statewide property tax limitation measure and reductions in FQHC reimbursements.

The Coalition for Multnomah County Communities in Charge includes more than 20 members.  The Coalition is comprised of OHSIC members (recognizing their valuable expertise and historical perspective on the issue).  It is also includes representative of government agencies, low-income healthcare consumers, minority populations, elected officials, businesses and others. 

The Multnomah County Communities in Charge Steering Committee represents a subset of the broader coalition of organizations and individuals.  Organizations represented on the Steering Committee include the following:

• Multnomah County Health Department

• CareOregon

• Oregon Health Sciences University

• Providence Health Systems

• Office of Oregon Health Plan Policy and Research

• Kaiser Permanente

• Legacy Health Systems

• Coalition of Community Health Clinics

• Oregon Department of Human Services

In Multnomah County, primary care clinics are run by the Health Department and non-profit organizations, combined with uncompensated care services by local hospitals, from a safety net health system that attempts to make healthcare available to the County's 73,000 uninsured residents.  Revenues to support the Health Department's primary care clinics include local general funds, state and federal grants, and sliding scale fees.  The safety net's non-profit community health centers (many operated by volunteers), and local care providers make significant contributions toward meeting the healthcare needs of Multnomah County uninsured residents.

In Multnomah County, Oregon there are no dedicated, long-term revenue sources to ensure that healthcare service for the uninsured are available from year to year, and safety net providers have experienced threats to their financial stability in recent years.  To address the challenges faced by the local safety net providers and to avoid a healthcare crisis among the uninsured population, the goal of Multnomah County Communities in Charge is to...

Implement a collaborative process designed to identify, evaluate, and establish a system of healthcare financing and delivery to ensure that Multnomah County's low-income uninsured residents have access to culturally competent, high quality, affordable, and compassionate healthcare.

Financing Strategy

Objective # 3 of the Communities in Charge project is designed to "establish and initiate a process to identify and evaluate alternative models to finance and deliver healthcare to low-income uninsured and underinsured residents."  This preferred financing strategy (and delivery system) will be identified as a product of Objective # 4 following the actuarial analysis of selected models.

Outreach Strategy

Outreach strategies will be identified as part of the project's Objective # 5 activities (market feasibility analysis and business planning).  The National Program Office will assist Multnomah County Communities in Charge with these activities.

Delivery System

As with the financing strategy, the proposed healthcare delivery system will be developed as part of the project Objective #3 and #4.  The project's coalition will play a significant role in terms of identifying and evaluating the appropriateness of alternative models for care delivery.  Preliminary discussion for the delivery system will emphasize a sustainable model that enhances the range of services currently provided and client access to social service, while assuring long-term funding stability.  Ultimately, a proposed delivery system (the product of Objective #4) will be presented to the County Board of Commissioners as a recommendation for action.

Multnomah County has a safety net system that consists of clinics operated by the Health Department, non-profit organizations and private providers.  Consequently, arriving at a consensus regarding significant system-wide changes will likely be the greatest challenge during the coming year.  The safety net's diversity of providers helps to serve the needs of different sub-populations among the county's uninsured residents.  However, because the organizations that make up the safety net have different philosophies in terms of financing and delivering care to the uninsured, the system's diversity may also have a downside when it comes to making changes.  For this reason, the coalition representing Multnomah County Communities in Charge has been structured to include individuals and organizations with a history of working together to make changes that are in the community's interest.

Geographic Area:  The targeted area for this project includes all of Multnomah County, Oregon.  The county occupies 450 square miles in northwestern Oregon.  The county's northern boundary is created by the Columbia River, which separates the states of Oregon and Washington.

Total Population:  Multnomah County occupies less than one percent of Oregon's land area, yet the county's 647,400 residents comprise 20 percent of the state's population.  Multnomah County is predominately urban: 79 percent of the county's population resides in the city of Portland - Oregon's largest incorporated community.  In terms of racial and ethnic composition, Multnomah County's population is 87 percent Caucasian (non-Hispanic white), 5 percent African-American, 4 percent Asian/Pacific Islander, 3 percent Hispanic, and 1 percent Native American.  Ethnic minorities in Multnomah County represent a significant percentage of the state's non-English speaking, non-white and Hispanic populations.  Multnomah County also has a large number of individuals affected by poverty.  More than 13 percent (84,809) of the county's population has incomes at or below the federal poverty level.

Uninsured Population:  The number of medically uninsured in Multnomah County was determined from demographic data gathered through the Oregon Population Society.  The survey is conducted on a county-by-county basis every two years.  The 1996 Survey generated data from a sampling of 4,366 Multnomah County residents.  It concluded that there are 73,000 people without health insurance.  11% of the population.  Of these, 53,600 (47 percent) live in households with income less than 200 percent of the Federal Poverty Level, younger adults (19-44 years old) are the largest group of low-income uninsured (59 percent of the total).  Half of uninsured adults work 20 or more hours per week.  The survey found that insurance coverage varies among ethnic groups, with the majority of the uninsured in Multnomah County being US-born non-Hispanic whites.

Target Population:  The target population for this project will include uninsured individuals who are not eligible to receive assistance through an existing subsidized health insurance program.  Examples of target population groups include the following:

• Low income (the poor and working poor) - According to the Oregon Population Survey, the number of Multnomah County residents whose income are below 200% of the Federal Poverty Level exceeds 182,000.  Of those individuals, 53,600 have no health insurance.  This group includes working families who are unable to afford healthcare insurance and whose employers do not provide insurance benefits.

• Minority populations - Minority populations include people of Hispanic, African-American, and Asian ethnicity, and foreign-born people.

• Individuals with social and cultural barriers - People who are homeless, mentally ill, disabled, chemically dependent, or do not speak English as their first language.

• Health plan ineligible - People who are ineligible to participate in a subsidized health insurance program because they do not meet income/assets criteria or cannot document their status as a legal resident of the United States.

The target population may be expanded to include additional groups as determined through the community assessment process (objective #2) of the Communities in Charge Project.

Michael E. Sorensen
Project Director
Multnomah County Health Department
1120 SW 5th, Suite 1430
Portland, OR 97201
Phone: (503) 248-3674
Fax: (503) 988-4117
E-mail:  michael.e.sorensen@co.multnomah.or.us